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opqu,;rnr San Joaquin County -- --- <br /> �'' ° Environmental Health DepartmAott 2 9 2007 SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwA,6tWNd)WMFdNT HEALTH UNIT IV <br /> N,P PERMIT/SERVICES <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoaqiuiniCounty Development Title,Chapte C9-1115ounty 3rand the Standards of Sanand/or <br /> Joaqu install <br /> Countywork <br /> Environmental HThis <br /> ealth DepartmentAs in compliance with San <br /> //�t Assessors <br /> WELLLocation 2No3 Laiu 14y1tiy@ Cross Street Cltyiylbdl'f![L Zip Parcetl 19g-IIB'oy <br /> SltDyclSs a rtlpcaS <br /> 27' <br /> PROPERTY A S�it p <br /> Owner r A <br /> dress <br /> C-57 Con1ractorY(tCOY1fX Address eta (�Checo Btvd, City l eco Zip Q4S53Lic#705g27 Phone#q�•521• INr'1� <br /> Consultant/Sub Cntr K 0411frAt Address 12'" U4_�"A �t✓�CiIy�MU b�f Licr#f� Phone# �t°��Z4 S' 4�a0 <br /> 14 Iqf ray E Section 25 <br /> GIS Coordinates::X 37 gl�N4l Y -01-2,6030y, ,Township YI S Range__b <br /> WORK TO BE PERFORMED: <br /> -/NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U AVER OVER-BORE. D (choose type below) <br /> OIL BORING# 'i ETER- <br /> 0 PRESSURE GROUT <br /> WELL# GROUT SPECIFICATIONS <br /> 0.Other <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING0 HOLLOW STEM DIA.OF BOREHOLE IS w 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA ------ <br /> 0 <br /> -- .0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ZS r TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> p AIR SPARGE/OZONE jtpUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes ;�4'"No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Y.SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ylrrf fond KwV_ stony rld; <br /> 0 OTHER' 0 OTHER APPROX.BORING DEPTH ZS ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or antes,Rules and Regulationss,, and all applicable California State Laws. <br /> Signed x <br /> 3 Q0. Dt Title/Company �CZ (y10V)4ge,4yl(20/t'CK <br /> � <br /> n e�ct �,maA-i; Data ��� aT� - o­l <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7 10 3 0 L&04r J 4V'k M"4CCcl <br /> WORK PLAN DATED: 1 i <br /> Date Issued 1 s IO 3h, Area <br /> Application Accepted B — �— Date <br /> Grout Inspection By <br /> Dale Final Inspection By <br /> Det cl n In pect on By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 799 It `*"'C'U 111-2 6f I z/3/�,} SR# 5Z71-12j D <br /> C-57-,-- WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHU 29-02-001 WEB <br /> 9111/2007 n q \ii <br />